Strong seasonality and Plasmodium vivax predominance of malaria in Malakand Division, Pakistan: a multi-district hospital-based study

Abstract Background: Though malaria is still a health issue in Khyber Pakhtunkhwa province, little information exists on the occurrence of malaria in Malakand Division as a whole. Thus, we measured the prevalence and number of various malaria species in hospitals in the Malakand Division and assessed how it differed by district, age, sex, and month of occurrence. Methods: We carried out a hospital-based cross-sectional study between March 2025 and February 2026 in seven district headquarters hospitals and 22 private hospitals located in Malakand Division. All symptomatic patients of various age groups were enrolled consecutively. A finger-prick blood sample was analyzed using thick and thin smears, the Giemsa method, and a rapid diagnostic test. The definition of prevalence was established with 95% confidence intervals, while the associations were determined using chi-square tests and logistic regression. Results . A total of 14,667 patients were examined, and 9,631 were found positive (prevalence 65.7%; 95% CI 64.9–66.4). Among the positive cases, Plasmodium vivax accounted for 87.8% and P. falciparum for 9.3%, while mixed infection accounted for 2.9%. There were significant variations in prevalence in different districts, from 12.8% in Lower Chitral to 82.0% in Lower Dir (Shangla 79.5%; p < 0.001); there were no cases in Upper Chitral. The gender-specific examination showed higher prevalence in males than females (69.1% vs 61.2%; OR 1.42, 95% CI 1.32–1.52). Age-wise, the prevalence was highest among 16–40-year-olds (83.7%) as compared to children (64.2%) and those aged 40 years and above (48.1%). There was a peak prevalence of 79.0% in August, and June–September accounted for 82.8% of positive cases. Conclusions: Malaria prevalence among the symptomatic individuals in the Malakand Division was high, seasonal, and highly influenced by the P. vivax species, and higher in adults and males. The results support district- and season-based control strategies and the need for species-specific diagnosis. Community and molecular studies should be carried out to determine the prevalence of malaria in the population.